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People who deal with arthritis are often stifled by debilitating pain as they make even the smallest of movements. Their limited range of motion can make physical therapy an agonizing endeavor. Because of this, many physical therapists followed the path sports teams took to soothe the aching muscles of their athletes. PTs find that treating this population with aquatic therapy provides a unique combination of pain reduction and fluid movement that allows breakthroughs in rehabilitation to occur.
"The most common conditions benefiting from warm water therapy are degenerative joint disease (osteoarthritis), rheumatoid arthritis, fibromyalgia, traumatic arthritis, bursitis, sciatica, and tendonitis. The number one consideration is the need for 'offloading' of the joint," explained Philip M. Allen, DPT, regional director of MX Physical Therapy in Rehoboth Beach, DE. "The joints may be most painful with weight bearing, which makes all activity painful and limited. The 'offloading' will allow the patient to exercise with minimum discomfort thus allowing them to meet their personal and clinical goals."
The Dover clinic of MX Physical Therapy is located right next to a 100,000 square foot senior center - so 85% or more of its caseload consists of patients with arthritis. When Dr. Allen recently saw a 71-year-old man admitted with a primary diagnoses of degenerative arthritis and degenerative disc disease of the lumbar spine, he started him on an aquatic program to initiate exercises (mainly stretching) and pain relief.
"His primary concern was the severe radicular pain, 'sciatica,' that was interfering with sleep and golf. He was able to progress to land therapy following six pool visits and returned to golf within 4 weeks," he told ADVANCE. "Many of our other patients receive care for symptoms secondary to knee osteoarthritis. Exercising in the warm pool allows each person to mobilize their knee with the assistance of the water, while the joint is offloaded with the assistance of the water."
Studies support this idea of relieving pressure on the joint so patients can make gains in the water that eventually transfer to their life on land. A study published in January 2007 showed that aquatic therapy resulted in significantly less pain and joint stiffness along with greater physical function, quality of life and hip muscle strength in participants dealing with hip and knee osteoarthritis.1 Aquatic therapy was 55-58% more successful than no activity was with the control group.
"Studies have shown that patients do progress quicker and recover to a greater extent when you use aquatherapy," agreed Michael Deluca, PT, of Pennsport Physical therapy in Philadelphia, PA. "It's very rewarding to see a person who was having difficulty doing any activity enjoy lower pain and more movement in the water. That success continues outside the water - people are really encouraged by the difference in movement they experience after a treatment session."
Science Behind the Soak
The natural buoyancy of water offers support for the body by diminishing the effects of gravity. As a result, it reduces stress on joints and muscles, while providing moderate compression for improved circulation to promote healing and improve muscle tone.
"There are different properties of water that allow for more movement," explained Elizabeth Duval, PT, of CP Rochester (NY). "The buoyancy decreases the weight and pressure on your joints making it much easier to walk and move. The water's temperature also helps with the pain, since it's typically kept at 93-94 degrees at all times. This assists with muscle relaxation and makes stretching less difficult in the water."
The relaxation caused by the warm water temperature may be particularly soothing for people who have frequent muscle spasms.
"Because the pressure increases with depth, standing in the water is like wearing a compression stocking - tighter on the bottom more than the top," added Dr. Allen. "Anyone with ankle or leg edema, varicose veins, or peripheral vascular disease as well as post-operative surgical edema may benefit from this property. The pressure also helps provide stability to those who require support from a cane or walker when on land. Whether it is the ankle, knee, hip or spine, all joints bearing weight and affected by the osteoarthritis will benefit from the aquatic therapy."
Treatments and Techniques
The first session in the pool is one where the patient spends time getting accustomed to the layout. Deluca often uses this time to let patients walk forwards, backwards and sideways slowly, all while identifying where the pool gets deeper, where the hand rails are for assistance, and where there is a seat for rest.
"We eventually move on to perform range of motion activities and more active mobility exercises," he said. "Balance exercises can be introduced and encouraged when weight bearing is an issue. Depending on the joint area involved, it's usually stabilization exercises and moving the limb against the water's resistance, with the speed increasing as the patient moves with less and less pain in subsequent sessions."
Duval often works with adults and children with developmental disabilities, so she starts by having patients hang on her hand or a floatation bar in the first session to increase their comfort level.
"We also do some swimming on their backs and stomachs in the beginning to get the blood flowing, along with stretching," she said. "Depending on where the arthritis is, we'll do different things but often for people with hip or knee arthritis, we have them work on general leg exercises, bending and straightening their knees, marching in place and hip abduction and extensions."
Many patients start with a 30 minute session, then might progress to a 45-minute session or more if there are several joints that need work. Devices like paddles and weights can be added as patients increase strength and range of motion. Duval also utilizes a weighted ball that allows patients to play soccer in the pool, which allows them to exercise their hips and knees. If standing balance is an issue, she might bring a basketball or volleyball into the pool so patients can practice stretching their arms in different directions while maintaining an upright position.
Who It's Right For
Physical therapists who specialize in this modality consider it for people who experience a lot of pain, since the water can minimize that aspect. Another important consideration is the patient's openness to the idea - some people just aren't comfortable with water in general or may take issue with going into a public pool.
"I typically show the patient the pool assuring them they do not have to swim and we have ample handrails. All patients are assured a therapist accompanies them at all times. In addition, multiple floats are available for those needing additional support. But the initial determination is the amount of pain contributed to weight bearing, then second are the number of body parts affected," Dr. Allen said. "I currently have a patient whose primary pain is shoulder pain followed by complaints of hip and knee pain secondary to rheumatoid arthritis, thus making it an easy choice to start with aquatics to quiet the multiple joint pain."
Most, if not all, of Dr. Allen's patients with an arthritic condition will start with aquatic therapy (if it's not contraindicated). The goal is to have them eventually progress to land therapy for aerobic conditioning or other modalities not provided in the water.
Contraindications for aquatic therapy include patients with MS, because their proclivity to fatigue will be exacerbated with the warm water, anyone with dermatological issues or sensitive skin, since they might be irritated by the chemically-treated water, and patients with a history of heart problems, who should have a physician or cardiologist clear them for participation beforehand. And anyone with an open wound cannot go the pool, of course.
Proven Results
Patients might be in aquatic therapy once a week from anywhere to a few weeks to several months. When Deluca worked with a 60-year-old teacher who was giving him pain levels of 8 out of 10 on a VAS scale, he found 2 months of aquatic therapy provided many benefits.
"Her job required her to stand for long periods of time, so she was experiencing regular, intense lumbar pain, decreased range of motion and strength reduction in her hips and legs," he said. "She had little relief with other modes of treatment, so we put her in the water for her second visit for walking and core strengthening. She was able to increase her strength and her pain levels went down to a 3 out of 10. She also increased her lumbar flexion by about 4 inches measuring from fingertips to floor when bending, and her strength in her extremities rose to 5 over 5."
A word of caution must be expressed because of the reduction in pain that patients experience. PTs must constantly assess the pace patients are progressing at, as they may overdo it in the water.
"You have to make sure they're not overworking themselves, so they don't get even more pain when they get out of the water," Duval said. "I see it happen all the time where patients come out and say 'that was more of a workout than I thought!' Because of the reduced-weight situation, you've got to move them slowly at the beginning to see what they're tolerating and how they are responding after the treatment."
It is, however, a very rewarding modality since physical therapists are able to see clients who are struggling on land experience a lot of success in the water. And because aquatics affords people with arthritis symptom-relief, PTs often see an improvement in compliance along with, ultimately, the successful completion of personal and clinical goals.
"It's wonderful to see patients in the water be able to do these tasks without pain and feel rewarded and proud of themselves," Duval said. "And a lot of the patients I work with are much more motivated because they consider this less like work and more like play."
Sarah Lebo is a freelance writer based in Royersford, PA.
Reference:
Hinman, RS, Heywood, SE, and Day, AR. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Phys Ther. 2007;87(1):32-43.
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